Internal Orifice Research Articles

Monitoring Cavitation Regime From Pressure and Optical Sensors: Comparing Methods Using Wavelet Decomposition for Signal Processing

A cavitating two-phase flow of water in a pipe with area shrinkage was experimentally investigated, acquiring at high sampling rate pressure signals and images of the cavitating flow-field. The fluctuations of the pressure measurements in the internal orifice and of the intensity level of the images' pixels were decomposed using the wavelet transform to analyze the frequency distribution of the signals energy with respect to the flow behavior and to highlight the influence of temperature on the phenomena under investigation. It was shown that the energy content at each frequency band of the acquired signals is well related to cavitation flow-field behavior.

Muscular Structure at the Male Bladder Outlet Examined With Successive Celloidin-embedded Slices

To re-examine the detailed anatomy of the muscular system at the bladder neck and proximal urethra in the male and to explore its function in urinary continence and micturition further. The pelvic organs, including bladder, prostate, and rectum, were obtained from 20 formalin-fixed adult male cadavers and were removed from the pelvic cavity and embedded in celloidin in their entirety. The embedded block was cut into successive slices with an immersing-alcohol microtome. Circular muscle fibers of the detrusor at the bladder outlet consist of the anterior downward-projected circular muscle fibers of the bladder outlet (ADPC), the bilateral accumulated circular fibers, and the posterior circular fibers of the bladder outlet. Together, these fibers concentrically surround the internal urethral orifice and trigone muscle. The lower part of the ADPC surrounds the ventral surface of the proximal urethra. Longitudinal muscle fibers are radially inserted into the circular muscle around the internal urethral orifice. Numerous fibers from the ventral longitudinal muscle are inserted into the lower part of the ADPC. The upper part of the trigone muscle exists in bladder cavity; the lower part extends into the proximal urethra to surround the posterior and posterolateral surface of the urethra. The ADPC and the upward extension of the rhabdosphincter comprise the anterior fibromuscular stroma. The circular muscle of the bladder outlet may be responsible for closure; the longitudinal muscle of the bladder outlet may be responsible for opening of the internal urethral orifice and proximal urethra.

Minimally invasive surgery for pyriform sinus fistula by transoral videolaryngoscopic surgery

Pyriform sinus fistula is a rare branchial anomaly that manifests as recurrent cervical infection resulting from contamination of the fistula internal orifice in the pyriform sinus. Although open neck surgery to resect the fistula has been recommended as a definitive treatment, identifying the fistula within the scar is difficult and occasionally results in recurrence. Here, we describe a novel transoral surgical technique for pyriform sinus fistula using transoral videolaryngoscopic surgery (TOVS) as a definitive treatment to resect and close the fistula without skin incision. Needle cautery enables fine excision and delicate dissection of the fistula tract. TOVS is a safe, easy, and reliable treatment and is a suitable first line treatment.

Adipose Tissue-Derived Regenerative Cell-Enhanced Lipofilling for Treatment of Cryptoglandular Fistulae-in-Ano: The ALFA Technique.

The treatment of complex fistulae-in-ano is challenging and often includes a number of operations due to high rates of recurrence. Recently, techniques using in vitro expanded adipose tissue-derived stem cells have been described. We describe a novel treatment for cryptoglandular fistulae used in 7 patients, using a combination of surgical closure of the internal opening and real-time autologous adipose tissue-derived regenerative cells (ADRC)-enhanced lipofilling, without need for in vitro expansion. Following exclusion of active perianal sepsis, patients underwent a standard tumescent liposuction procedure, harvesting ~300 to 400 mL of raw lipoaspirate. The lipoaspirate was prepared in real time, using the Celution 800/CRS system to obtain the stromal vascular fraction containing ADRCs. After excision of the fistula tract and closure of the internal orifice, fresh ADRC-enhanced lipoaspirate was injected into and around the fistula tract. At 6-months' follow-up, 5 of 7 (71.4%) patients showed clinical signs of fistula closure; one of these patients had a recurrence at 10 months due to sepsis. The remaining 4 patients (57.1%) all had complete fistula closure at a median of 46 months' follow-up. There were no adverse events associated with the technique, and no new incontinence. Treatment of cryptoglandular fistulae-in-ano with ADRC-enhanced lipofilling appears feasible and safe, and may add to the range of procedures that can be used to treat this difficult problem.

Feasibility and related outcome of intraluminal pulmonary artery banding.

This retrospective study evaluated the feasibility and related outcome of intraluminal pulmonary artery banding (I-PAB). Thirty-two children underwent I-PAB between July 2006 and April 2014. The median age and weight were 60 days (range: 5 days to 4.2 years) and 3.7 kg (range: 2.6-13.0 kg), respectively. Cardiac diagnoses included single ventricle morphology (n = 11), complex ventricular septal defects (n = 11), balanced atrioventricular septal defects (n = 3), congenitally corrected transposition of the great arteries (n = 2) and aortic arch hypoplasia with ventricular septal defects (n = 5). On cardiopulmonary bypass (CPB), 2 I-PAB modifications with either 1 (n = 24) or 2 ('hour-glass-technique', n = 8) fenestrated pericardial patches were performed. The median fenestration size was 5 mm (range: 4-6.5 mm). In 18 patients I-PAB was a solitary procedure; in 3 of them the decision was made intraoperatively. There was no hospital mortality. The median interval to debanding was 189 days (range: 112 days to 2.6 years). During this period, we observed a significant increase in the pressure gradient over I-PAB (P < 0.01), whereas arterial saturations remained stable. Four patients received balloon dilatation of I-PAB to prolong the palliation period. No patient experienced band occlusion, pulmonary hypertension related to I-PAB, coronary or pulmonary valve impairment. Debanding was performed in 27 patients and one of them required pulmonary patch arterioplasty due to I-PAB-associated pulmonary trunk distortion. Three patients are still awaiting further surgery. There were 2 late deaths prior to, and 3 after debanding, all not related to I-PAB. I-PAB with an exactly defined internal orifice is feasible and effective. Although arterial saturations seem to remain stable, balloon dilatation of I-PAB can be performed safely and efficiently in order to prolong the palliation period. The rate of I-PAB-related complications is low, which might improve the long-term patient outcome. Therefore, despite requiring CPB, I-PAB is our institutional preference for children who require pulmonary artery banding.

Congenital urethrovaginal fistula associated with imperforate hymen causing fetal urinary ascites and abdominal cystic lesions: A case report and literature review

Abstract A primipara presented to our hospital due to fetal ascites, bilateral hydronephrosis and hydrometrocolpos. The female baby had two giant abdominal cysts, a single atrium and foot polydactyly. Absence of the vaginal orifice was noticed, and the hymen was broken through; the left cyst collapsed after fluid drainage. The right cyst was punctured and drained, which improved the hydronephrosis. Contrast imaging showed medium pouring into the abdominal cavity via the uterine tube; the right cyst was a 6 × 5 cm closed cavity. Vaginal uroplania persisted even after hospital discharge. At the age of 4 years, cystoscopy showed a fistulous opening on the urethra 5 mm distal from the internal urethral orifice. A catheter inserted via the opening was found in the vagina. In our case, urine poured into the abdominal cavity through the fistula and uterine tube; following obstruction of the uterine tube, giant hydrometrocolpos and hydrosalpinx appeared. Three cases of congenital urethrovaginal fistula (CUVF) with imperforate hymen have been reported. A remnant of communication between the uterovaginal primordium and urogenital sinus may be responsible for CUVF.

Platelet-Rich Fibrin Sealant as a Treatment for Complex Perianal Fistulas: A Multicentre Study

IntroductionThe incidence of perianal fistulas is high, and this condition has a profoundly negative impact on patients’ quality of life. The problem is greater when the fistula tract is high because treatment is necessarily complex (limited surgery may lead to recurrence, while aggressive surgery is associated with higher rates of faecal incontinence). To achieve a balance between these two options, we suggest that complex fistulas should be treated by sealing the tract with platelet-rich fibrin. Our objective is to evaluate the medium- to long-term results obtained from the treatment of complex perianal fistulas by sealing with platelet-rich fibrin. Material and MethodsProspective longitudinal multicentre study involves three colorectal surgeons working at three hospitals. The study period was October 2010 to June 2013, during which a total of 60 patients were treated for complex fistulas. In all cases, the intervention consisted of curetting the fistula tract, sealing it with platelet-rich fibrin and closing the internal orifice. We evaluated the clinical outcomes (clinical examination and pelvic magnetic resonance (MRI)) and the quality of life results, both general (SF-36) and gastrointestinal (GIQLI questionnaire) in periodic reviews during consultation. ResultThe median follow-up period was 24 months (11–43 months), during which in 40 patients (66.66 %) the fistulas remained closed, with a zero rate of faecal incontinence. The results of the quality of life questionnaires are comparable (indeed, they are better in some items for the cured patients) to those of the reference population. ConclusionIn our opinion, this procedure is safe and its results are promising in terms of clinical outcome and medium- to long-term quality of life.

How does internal angle of hoppers affect granular flow? Experimental studies using digital particle image velocimetry

Mechanical behaviour of powders and grains often displays features of solid-like and liquid-like characteristics of matter. In spite of processing granular materials quite extensively in the industries, their flow behaviour is still complex to understand under different process conditions. In this paper, using digital particle image velocimetry (DPIV) and high speed videography, we probe systematically on the spatial and temporal distributions of the velocity fields of pharmaceutical excipient granules flowing though smooth hoppers with different internal (orifice) angles. This helps to visualise and identify the locations and formation of the flow channels and conversely the stagnation zones of granular materials inside the hoppers as a function of the internal angle of the hoppers. We show that even when a powder characterised as a free-flowing type in the conventional sense could experience a significant level of hindrance to flow even when passing through smooth hoppers of different internal angles, and its impact increases with an increase in the internal angle. Theoretical predictions are made using experimentally evaluated grain-scale properties as input parameters for understanding the effects of hopper angle on the granular flow rate. A good level of agreement is obtained between the experimental and theoretical estimates of the granular flow rate in terms of the hopper angle. The outcomes presented here are a step forward in designing granular flow devices more efficiently in the future.

Early indicators of cervical insufficiency assessed using magnetic resonance imaging of the cervix during pregnancy

Objective: To establish the main characteristics of the cervix in pregnant women with cervical insufficiency, by means of magnetic resonance imaging (MRI).Methods: A prospective observational case-control study was conducted among 59 pregnant women with cervical insufficiency and 10 normal pregnant women, between their 10th and 28th weeks. The parameters analyzed in the MRI examinations were: precise identification of the cervix; presence of hyposignal at the internal orifice of the cervix; loss of definition of the periendocervical stromal zone (PESZ); presence of hyposignal content inside the amniotic sac (sludge sign) and anatomical and functional biometry of the cervix.Results: Peripheral hyposignal was found in 41 (85.4%) and loss of definition of the PESZ was observed in 36 pregnant women (73.5%) with cervical insufficiency. Sludge was observed in 46 pregnant women with cervical insufficiency, and this was seen on MRI in 27 cases (58.7%). The mean anatomical and functional lengths of the cervix on MRI in the pregnant women with cervical insufficiency were 3.5 ± 0.8 cm (0.8–4.9 cm) and 28.7 ± 6.3 mm (9–41 mm). None of the normal pregnant women presented hyposignal loss of the PESZ and the sludge sign.Conclusion: MRI may be useful for evaluating the cervix and for early identification of signs of cervical insufficiency during pregnancy.

Implantation of Autologous Adipose-Derived Cells Reconstructs Functional Urethral Sphincters in Rabbit Cryoinjured Urethra

We investigated the ability of autologous adipose-derived cells injected into cryoinjured rabbit urethras to improve urinary continence and explored the possible mechanisms by which it occurred. Adipose tissue was harvested from the perivesical region of nine 10-week-old female New Zealand White rabbits and cultured for 7 days. Immediately after harvesting the tissue, we injured the internal urethral orifice by spraying liquid nitrogen for 20 s. The cultured cells expressed the mesenchymal cell marker STRO1, but not muscle cell markers myoglobin or smooth muscle actin (SMA). Just before implantation, the adipose-derived cells were labeled with the PKH26 fluorescent cell linker. Autologous 2.0×10(6) adipose-derived cells (five rabbits) or a cell-free control solution (four rabbits) was injected around the cryoinjured urethras at 7 days after injury. Fourteen days later, the leak point pressure (LPP) was measured, and the urethras were harvested for immunohistochemical analyses. At 14 days after implantation, LPP of the cell-implanted group was significantly higher compared with the cell-free control group (p<0.05). In immunohistochemical examination, the reconstructed skeletal and smooth muscle areas in the cell-implanted regions were significantly more developed than those in controls (p<0.01). Implanted PKH26-labeled adipose-derived cells were immunohistochemically positive for myoglobin, SMA, and Pax7 antibodies, which are markers for skeletal muscles, smooth muscles, and myoblast progenitor cells, respectively. In addition, these implanted cells were positive for the nerve cell markers, tubulin β3, S100, and the vascular endothelial cell marker, von Willebrand factor. Furthermore, some of the implanted cells were positive for the transforming growth factor β1, nerve growth factor, and vascular endothelial growth factor. In conclusion, implantation of autologous adipose-derived cells into the cryoinjured rabbit urethras promoted the recovery of urethral function by myogenic differentiation, neuroregeneration, and neoangiogenesis of the implanted cells and/or the surrounding tissues as well as by bulking effects. Thus, treatment of human radical prostatectomy-related stress urinary incontinence by adipose-derived cell implantation could have significant therapeutic effects.

Single-Port Laparoscopic Percutaneous Extraperitoneal Closure Using an Innovative Apparatus for Pediatric Inguinal Hernia

Laparoscopic procedures for pediatric inguinal hernia (PIH) have numerous techniques and continue to evolve, with a trend toward increasing use of extracorporeal knotting and decreasing use of working ports and endoscopic instruments. Single-port laparoscopic percutaneous extraperitoneal closure (SPLPEC) with variable devices seems to be one of the most simple and reliable methods. Here the authors describe and evaluate the applicable effects of SPLPEC using an innovative two-hooked core hernia apparatus. Between June 2008 and October 2011, 72 children with indirect inguinal hernia underwent SPLPEC with an innovative two-hooked core hernia apparatus. A 5-mm laparoscope was placed through a transumbilical port. Without an assistant working port, the two-hooked core hernia apparatus with a 2-0 nonabsorbable suture was inserted at the point of the internal inguinal ring. It could be readily kept in an identical subcutaneous path for introducing and withdrawing the suture. The extraperitoneal knot-tying could tautly enclose the hernia defect without peritoneal gaps and upper subcutaneous tissues. During the same period, 63 cases with PIH underwent SPLPEC with a single-hooked hernia device. Technical essentials, mean operation time, and intra- and postoperative complications were compared. The internal orifice was closed faster by SPLPEC with the innovative two-hooked core apparatus than with a single-hooked device (unilateral, 13.21±3.86 versus 17.92±4.37 minutes [P<.05]; bilateral, 17.18±4.69 versus 25.36±7.38 minutes [P<.01]). There were no postoperative complications or evidence of early recurrence in the two-hooked group. However, one recurrence and one subcutaneous knot granuloma were postoperatively observed in the single-hooked group. SPLPEC with the two-hooked core apparatus was proved to be a successful procedure without leaving a peritoneal gap and ligating subcutaneous tissues. It is safe, feasible, and reliable for PIH.

Ultrasound in placental disorders

The definition of placenta previa based on ultrasound findings is more practical, and the traditional definition (implantation of the placenta in the lower uterine segment) needs to be revised. The term 'placenta previa' should only be used when the placental edge overlaps or is within 2 cm of the internal cervical orifice in late pregnancy. If the placental edge is located further than 2 cm but within 3.5 cm from the internal cervical orifice, the placenta should be termed 'low-lying'. Unless the placental edge at least reaches the internal orifice at mid-trimester, symptomatic placenta previa in the third trimester will not be encountered. Caesarean section is the recommended mode of delivery for placenta previa at term. Attempt at vaginal delivery is appropriate for low-lying placenta, but the possibility of post-partum haemorrhage should be kept in mind. The incidence of invasive placentation, such as placenta accrete, has progressively risen in the past 3 decades, possibly as a consequence of increasing caesarean section rates. Ultrasound has a sensitivity of 91% and a specificity of 97% for the identification of all forms of invasive placentation. Chorioangiomas are benign non-trophoblastic placental tumours with excessive vascular proliferation within the stroma of chronic villi. They are usually asymptomatic, although occasionally can be associated with adverse fetal outcomes. Chorioangiomas usually appear as well-circumscribed, rounded, hypo-echoic lesions next to the chorionic surface. Iatrogenic delivery or prenatal intervention are two options, if fetal compromise is present. Prenatal detection leads to a dramatic increase in survival compared with those cases unsuspected antenatally.

Optimizing the Temperature of Hot outlet Air of Vortex Tube using Taguchi Method.

Vortex tube produces hot and cold streams from inlet pressurized gas. Though mainly used for spot cooling purposes, it may also be used for heating/pre-heating applications. In this work, the effect of - inlet air pressure, hot tube length, hot tube internal diameter, orifice diameter, and nozzle diameter, on hot-outlet air temperature is analyzed. Taguchi's parameter design approach is used to optimize the response. Above parameters are considered at three levels each. L-27 Orthogonal Array is used for experimentation with two replicates. From the ANOVA table, all the parameters considered are found to be statistically significant. Relevant graphs are drawn; optimum response value at optimal factor levels is predicted. Through confirmatory test, experimental results are validated.

An artificial neural network approach to investigate cavitating flow regime at different temperatures

Identification of cavitating regime is an important issue in a wide range of fluid dynamic systems. The cavitation behavior is affected by several parameters, as the operating pressure and the fluid temperature. In the present study the cavitating behavior of water inside an orifice was analyzed by images analysis and by pressure signals. Four cavitation regimes were characterized: no-cavitation, developing cavitation, super cavitation and jet cavitation. A three-layer Elman neural network was designed to predict the cavitation regime, from the frequency content of the pressure fluctuations, recorded upstream and downstream the internal orifice. Cavitation regimes were successfully predicted. The designed neural networks were useful also to underline the influence of each operating parameter on the phenomena under investigation; in particular it was possible to identify the frequency ranges that characterize the different cavitation regimes and the influence of the fluid temperature.

Movement of Internal Canalicular Orifice in Association With Blinking: Direct Observation After Dacryocystorhinostomy

To examine movement of the internal canalicular orifice with blinking and lacrimal drainage under endonasal endoscopic observation after dacryocystorhinostomy. Observational anatomic study. Twenty internal canalicular orifices (right 9, left 11) from 15 patients (age range: 44-77 years) who underwent endoscopic endonasal dacryocystorhinostomy were prospectively examined. The patients sat on a chair with the chin projected slightly upward while digital images were taken. After examining the movement of the internal canalicular orifice with blinking, the patient's eye was stained with fluorescein dye, and diffusion from the orifice was examined with blinking. The internal canalicular orifice closed during eyelid opening, although always incompletely. In eyelid closing, the orifice opened, and was pulled laterally without folds. All 20 internal canalicular orifices formed a diverticulum. Three specimens illustrated the upper and lower canalicular ends emptying into the diverticulum. The closing of these canalicular ends was always incomplete. Movement of the internal canalicular orifice was slight during normal blinking, but forced blinking resulted in more movement. Movement of the lacrimal sac wall was slight. During the first few seconds without blinking, no fluorescein dye flowed from the orifice. After several blinks, fluorescein dye flowed out slowly from the orifice, and increased in volume with more blinking. The fluorescein dye traveled inferiorly by gravity. A forced blinking was related to more dye inflow. The internal canalicular orifice incompletely closed during eyelid opening, but this orifice largely opened during eyelid closing, with a slow gravitational inflow of lacrimal fluid.

Prospective cohort study and meta-analysis of cyclic bleeding after laparoscopic supracervical hysterectomy

ObjectiveTo evaluate a modified technique of laparoscopic supracervical hysterectomy (LSH) on rates of postoperative cyclic bleeding (PCB). MethodsA retrospective study was conducted of 173 women who underwent LSH with bipolar electrocoagulation of the endocervical canal at Landeskrankenhaus Wolfsberg, Wolfsberg, Austria, between January 1, 2005, and December 31, 2009. Long-term follow-up was assessed using a questionnaire. A systematic literature review and a meta-analysis of 13 studies that reported on PCB after LSH were also conducted. ResultsIn all, 164 women (94.8%) had uneventful intraoperative and postoperative courses. By contrast, 9 of 146 premenopausal women (6.2%) experienced PCB. The meta-analysis (n=1822) revealed an overall PCB rate of 7.1%. Bipolar electrocoagulation of the endocervical canal was the most effective method for prevention of PCB (bleeding rate, 2.9%) followed by unipolar electrocoagulation (bleeding rate, 9.9%). Uterine resection below the internal cervical orifice was more effective for preventing PCB (13 of 633 women; 2.1%) than either amputation at this site or above this site (27 of 537 women [5.0%] and 88 of 640 women [13.8%]). ConclusionBipolar coagulation of the endocervical canal and extensive resection with amputation below the level of the internal cervical orifice were effective for reducing rates of PCB.

Nonligation of indirect hernia sac in senior male patients with dilated internal ring

Summary Background There is a debate about how the indirect hernia sac should be treated in order to prevent hernia recurrence. Recently, nonligation treatment of the indirect hernia sac has been proposed and performed successfully in patients with nondilation of the internal ring. Aims To evaluate the feasibility of nonligation of the indirect hernia sac among patients with a dilated internal ring. Materials and methods Data were gathered from January 2005 to August 2008. Patients from two regional hospitals included 117 senior male patients with indirect inguinal hernia and medium or large internal ring orifices. The patients were divided into two groups: a ligation group and a nonligation group. Simultaneous posterior wall reinforcement with Shouldice repair was performed on both groups. Results In the ligation group, high-ligation of the indirect hernia sac was performed in 60 patients with 62 hernia repairs. In the nonligation group, nonligation treatment of the hernia sac was performed in 57 patients with 60 hernia repairs. The postoperative pain intensity ( p = 0.730) and complication rate ( p = 0.560) were similar between the two groups. After a 3-year follow up period, six patients (10%) in the ligation group and eight patients (14%) in the nonligation group were lost to follow-up. The recurrence rate of indirect hernia was similar in both groups ( p = 0.893). Conclusion In senior male patients with a dilated internal ring, nonligation treatment of the indirect hernia sac is a safe procedure with no adverse influence on indirect hernia recurrence if a simultaneous posterior wall repair is performed.

A New Surgical Device for Minimally Invasive “Core-Out” Excision of High Fistula-in-Ano

Core fistulectomy with endorectal advancement flap repair has been reported as a safe and effective technique for treatment of high fistula-in-ano. A number of rigid and flexible fistulectomy sets have already been fabricated pursuing the objectives of facilitating the procedure of this conservative surgical technique and reducing its risks of continence impairment. Two different methods (the method of scraping the granulation tissue of fistula and the method of separating and removing a thin layer from inside of tract) have been served in these sets for obliterating the abnormalities. In this work, with the aim of minimizing invasion to healthy tissue encircling the fistula, specially sphincter muscles, we designed and fabricated a new flexible fistulectomy device, which uses the second mentioned method. The new set separates an approximately 2.5-mm-thick layer from inside of the fistulous tract, by rotating a special tubular blade around its axis and moving the blade along the fistulous tract from external orifice toward the internal orifice. At the same time, the separated tissue may be removed from the fistulectomy lumen by rotating a special cannulated screw embedded coaxially inside the tubular blade. A flexible guidewire was used for identifying the tract path and guiding the device along it. We used the new set for excising 10 curved fistula models of approximately 16 cm length and 1.5 mm diameter, which were created in cubic pieces of fresh cow muscle as test specimens. After removing the device, each specimen was left with a smooth-walled lumen of approximately 9 mm diameter. The tubular blade works very well in separating a thin layer from inside of the fistula models and the cannulated screw is capable of easily removing the separated tissue. The removed tissue could be used as a sample of the whole tract for histopathological examinations. The screw and flexible guidewire lead the blade along the tract in a good manner and ensure circumferential separation of the fistula. With regard to the results of our tests, it is anticipated that the new set is an efficient instrument for easy, safe and fast core-out excision of high anal fistulas and is able to reduce the risk of injuries to healthy tissue encircling the fistulous tract.

Exceptional dissemination of perineal tuberculosis up to the right flank: a tribute to J.P. Nesselrod’s study on the anatomy of pelvic lymphatics published in 1936 in the Annals of Surgery

A 56-year-old cachectic male in poor general and hygienic condition collapsed and was subsequently admitted to hospital in a severe sepsis. The personal history was negative for preexisting intraabdominal and cardiorespiratory ailments. Recent journeys to tropical countries were denied. However, a lengthy stay at a psychiatric clinic due to alcohol abuse several years ago was noteworthy. The patient had been suffering from perineal fistula for years without any medical treatment. At admission, we found a complex of perianal and gluteal abscesses with involvement of the skin of the right lower back. The abdomen was clinically unsuspicious. The laboratory studies revealed a severe inflammatory syndrome measuring a white cell count of 30×109/L, CRP value of 226 mg/L, and slightly elevated procalcitonine with 0.47 μg/L. A CT scan revealed an extensive subcutaneous abscess on the right flank with involvement of the right iliopsoas muscle (Fig. 1), the presacral space, the fossa ischiorectalis with involvement of the external sphincter, and the levator ani (Fig. 2a–c) with subcutaneous fistula in the perianal region and the adjacent right gluteus. However, no internal orifice was found by rigid rectoscopy. An endoanal ultrasound to investigate the presence of transor intersphincteric fistula was omitted due to the patient's bad condition. The MRI performed to analyze whether there was an involvement of vertebral bodies or an involvement of intervertebral disks was not suitable to evaluate the anal sphincter. There were no particular intraabdominal findings such as significant lymphatic nodes, wall thickening of the bowel, or ascites. All findings were restricted to the extraperitoneal space. Despite immediate surgical drainage of the subcutaneous abscess on the right flank and in the perianal region as well as antibiotic treatment with piperacilline/tazobactam, the patient's condition showed signs of deterioration such as weight loss, hypotension, and fever. Additionally, upcoming perianal abscesses were surgically evacuated, and the presacral space was partially drained initially by CT-guided puncture and finally emptied by open surgery over an extraperitoneal right–anterior access to the right iliopsoas muscle. The drained perianal wounds did not show any signs of healing and continued to produce serous turbid secretion. Crohn's disease was suspected early, but not confirmed in an ileocolonoscopy. The microbial culture from R. Rosso Department of General Surgery, Ospedale Regionale di Lugano, Via Tesserete 46, CH-6900 Lugano, Switzerland

Оценка конструктивного стеноза механических клапанов сердца у взрослых в аортальной позиции: преимущество полнопроточного протеза клапана сердца

The analysis of transprosthetic hemodynamics in adults after aortic valve replacement in the Bakoulev Center for Cardiovascular Surgery in 2007-2010 demonstrated the hemodynamic advantage of the concept of new full-flow mechanical aortic valve prosthesis "CorBeat". Having the same size of internal orifice and tissue annulus diameters, the values of transprosthetic parameters (peak and mean gradients, blood flow velocities) through "CorBeat" were close to physiological values of transvalvular native aortic parameters and had a tendency to be not dependent on the size of prosthesis (p = 0.63). In the article for the first time a morphometric database of geometric values of internal orifice area of normal native aortic valves in adults was used taking into account both the gender and the body surface area's of a patient. There was also used the standardized prosthesis size Z-score which represents the number of SDs by which the internal prosthesis area differs from the mean normal native aortic valve area for the patient's body surface area. The article emphasizes the need of the personal selection of the size and the type of prosthesis for any patient as well as the need for new design development of prosthetic heart valves.